"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

July 28, 2015

More than 6 million people in Yemen are on the verge of starvation, Oxfam warned on Tuesday, adding that months of war and a blockade on imports were pushing an additional 25,000 people into hunger every day.

One in two of Yemen's people - nearly 13 million - are now struggling to find enough to eat, the aid agency said.

"As the warring parties continue to ignore calls for a ceasefire, the average family in Yemen is left wondering when their next meal will be," Oxfam's Yemen country director Philippe Clerc said.

Nearly 4,000 people have been killed and more than 1.2 million displaced in a conflict between Houthi rebels and forces loyal to exiled President Abd-Rabbu Mansour Hadi. Four fifths of the population need help, the United Nations says.

Oxfam said the number of hungry people had risen by 2.3 million to 12.9 million since March, when a Saudi-led coalition backing Hadi began bombarding the Houthis and imposed a blockade in a bid to cut off arms supplies.

"In a country that has historically faced food shortages, this is the highest ever recorded number of people living in hunger," Oxfam said in a statement.

It said the blockade had exacerbated the humanitarian crisis in Yemen, which imports up to 90 percent of its food and the majority of its fuel.

U.N. humanitarian coordinator for Yemen Johannes van der Klaauw said more than 6 million people were in an emergency food situation - the phase before famine on the internationally used food security scale.

June 22, 2015

Climate change threatens to undermine half a century of progress in global health, according to a major new report.

But the analysis also concludes that the benefits to health resulting from slashing fossil fuel use are so large that tackling global warming also presents the greatest global opportunity to improve people’s health in the 21st century.

The report was produced by the Lancet/UCL commission on health and climate change, a collaboration of dozens of experts from around the world, and is backed by Margaret Chan, head of the UN World Health Organisation.

“We see climate change as a major health issue and that it is often neglected in the policy debates,” said Professor Anthony Costello, director of the UCL Institute of Global Health and co-chair of the commission.

“On our current trajectory, going to 4C [of warming] is somewhere we don’t want to go and that has very serious and potentially catastrophic effects for human health and human survival and could undermine all of the last half-century’s gains. We see that as a medical emergency because the action we ned to do to stop that in its tracks and get us back onto a 2C trajectory or less requires action now – and action in the next ten years – otherwise the game could be over.”

The comprehensive analysis sets out the direct risks to health, including heatwaves, floods and droughts, and indirect – but no less deadly – risks, including air pollution, spreading diseases, famines and mental ill-health. A rapid phase-out of coal from the global energy mix is among the commission’s top recommendations, given the millions of premature deaths from air pollution this would prevent.

The report states that political will is now the major barrier to delivering a low-carbon economy and the associated improvements to health and poverty, not finance or technology.

The authors argue that health has been neglected from the climate change debate. It says doctors and other health professionals must take a leading role in ending society’s “addiction” to fossil fuels, having confronted “powerful entrenched interests”, such as the tobacco industry, in the past.

“A public health perspective has the potential to unite all actors behind a common cause — the health and wellbeing of our families, communities, and countries,” the report states. “These concepts are far more tangible and visceral than tonnes of atmospheric CO2, and are understood and prioritised across all populations.”

May 21, 2015

A global weather phenomenon could cause a famine in the Sahel this year by combining with already dry conditions to create a “double whammy” for the region, scientists and aid groups have warned.

Professor Adam Scaife, a long term forecaster at the UK Met Office Hadley Centre, said models now agreed an El Niño event was likely and the first impacts may be felt as early as June.

El Niño is caused by a reversal of trade winds in the Pacific that allow warm water to spread east, across the ocean. The two to seven year cycle plays havoc with weather across the world.

“[A] place that’s really important to stress is west Africa, where there is increased risk of drought during El Niño. That is exacerbated this year by some conditions [including] cooling of the North Atlantic,” he said.

In west Africa, Scaife said conditions were aligning in a similar way to the massive 1972 drought that devastated the Sahel with famine. During this event, drying from El Niño tipped the region into full blown drought.

Scaife said the current parched conditions combined with further warming and drying from El Niño would be a “double whammy”.

Oxfam’s west Africa regional director Aboubacry Tall said the partial failure of the 2014 rainy season had left between 300,000 and 400,000 people in the Sahel without access to a secure food supply.

Speaking to the Guardian from Sierra Leone, Tall said the first rains of 2015 began to fall just a few days ago and Met Office predictions of a drought as early as June were deeply concerning for people awaiting crop-growing rain in the sub-Saharan areas of northern Nigeria, Niger, Chad, Mali, northern Senegal and Mauritania.

“If this rainy season is disrupted then the consequences would be quite drastic because even this year we have some gaps. If you have a second generalised failure of crops across the region you will certainly have the early set in of a food crisis or possibly a famine in the Sahel,” he said.

On Wednesday, US president Barack Obama linked the violence and terror being wrought in Nigeria by Boko Haram to severe drought in the Sahel. It has been reported that young men have joined the al-Qaeda affiliated group after being displaced by food shortages.

In the neighbouring coastal countries mounting a fragile recovery from ebola, Scaife said the effect of a possible El Niño was less clear. These areas are traditionally wetter and are more resistant to fluctuations in rainfall. “If anything it is more likely wetter on the Guinea coastline,” he said.

This news will come as a relief in countries where people have been driven from their farms and food production has dropped significantly.

“If El Niño was to [cause drought] on top of ebola in affected countries it would certainly be a significant catastrophe in Liberia, Sierra Leone and Guinea. It would put back any hope of recovery by at least another year,” said Tall.

On 5 April 1815, a titanic explosion hurled a cloud of ash to a height of more than 30km. Violent, but short-lived, the blast lasted just two hours, after which the volcano returned to a state of brooding menace.

According to the lieutenant governor, Thomas Stamford (later Sir Stamford) Bingley Raffles, to whom volcanologists are indebted for his accounts of the eruption, the detonation was so loud that it was mistaken across Java for cannon fire, causing consternation among the British troops, which had ousted the Dutch and French forces just a few years earlier.

But the blast was small beer in comparison with what followed. After five days of relative calm, the climactic phase of the eruption began with a colossal explosion that launched a towering column of ash to the edge of space.

For four or five days, utter blackness reigned across the island as the hurricane blasts of hot ash and scalding gas – known as pyroclastic flows – scoured the flanks of the volcano of everything and everyone, and drifts of ash metres thick entombed what few signs of life remained.

When the explosions ceased and the darkness finally lifted, the view revealed was a vision of Tolkien’s Mordor; a grey landscape within which nothing lived or moved. The top 500m of the volcano was gone, blasted into smithereens, and replaced by a 6km-wide maw from which steam spiralled skywards.

Communities on the flanks of the volcano had vanished, along with the lives of around 12,000 men, women and children. These, perhaps, were the lucky ones, as a further 60,000 survivors of the eruption succumbed slowly and agonisingly to famine or disease.

But the consequences were not confined to this Indonesian backwater. The explosion was heard 2,600km away in Sumatra, while giant rafts of floating pumice – some kilometres in length – clogged shipping routes for years. The 50 cubic kilometres or so of ash ejected over the course of the eruption returned to earth in the following days and weeks, leaving a thick covering as far away as Borneo, 500km to the north.

In addition to the ash, an estimated 200 million tonnes of microscopic sulphur particles pumped into the stratosphere, spread outwards from Sumbawa to form a giant aerosol veil that enclosed the planet and acted as a block to incoming sunlight.

The consequences for the developed societies of the northern hemisphere were dire. A dry, sulphurous, fog draped itself across the landscape of eastern North America, causing temperatures to plunge and bringing unprecedented summer cold. In New York State, snow fell in June, while the bitter cold and killing frosts wiped out crops and halved the length of the growing season across much of the region.

On the other side of the Atlantic, Europe saw summer temperatures down by 2C compared to the average for the decade; the unseasonal cold accompanied by incessant rains and – into the following winter – by unusually powerful storms. Analysis of climate records reveals that 1816, the so-called “year without a summer”, was the second coldest in the northern hemisphere of the past six centuries.

The alleged cultural implications of this “volcano weather” for Europe are somewhat whimsical. The brilliant, gas-charged, sunsets have been declared by some to have provided the inspiration for some of JMW Turner’s more flamboyant skies. In a similar vein, the damp and gloom of the 1816 summer has been charged with setting the scene for both Lord Byron’s grim vision Darkness, and Mary Shelley’s gothic novel Frankenstein.

For the less well-to-do of Europe, however, the Tambora eruption brought nothing less than hunger, disease and death. Widespread harvest failure resulted in the most serious famine for more than a hundred years, doubling the price of grain and spawning bread riots and widespread civil unrest.

Such was the degree of breakdown of food supply that economic historian John Post has called the episode “the last, great subsistence crisis in the western world”. Malnourished and weakened, the starving succumbed rapidly to disease, with typhus in particular rife. Many tens of thousands are thought to have died across the continent, including more than 40,000 in Ireland alone.

Click through to read some informed speculation on how we might handle such an eruption today. Eric Klemetti's Eruptions blog discusses just how big the eruption was. In 2013 I wrote a review in The Tyee of a book about the impact of Tambora.

January 14, 2015

Thanks to Ebola Trending News for tweeting the link to this important article in The Atlantic: Ebola’s Hidden Costs. It's a useful antidote to the premature euphoria I sense in the reports about declining (or even level) case incidence. Excerpt (but read the whole thing):

Even as Ebola infection rates appear to be leveling off in the country, the disease’s less visible but long-term impacts on communities and the economy are taking shape.

On December 17, the UN Food & Agriculture Organization (FAO) and the World Food Program estimated that 120,000 Sierra Leoneans have become “food insecure” as a result of Ebola, meaning they neither have the food they need nor are able to buy it. By March, the report predicted, the number will rise to 280,000. In other words, the number of people in Sierra Leone who have died from Ebola—just over 3,000, to date—will be only a fraction of the number who will go hungry from it.

This is in large part because Ebola poses an almost impossible quandary in Sierra Leone, where the outbreak has taken the greatest human toll. Prevention of the disease requires people to distance themselves from one another.

But agriculture, the country’s lifeblood, relies on people coming together. If the quintessential image of American farming is a lone figure riding a tractor or a combine, the picture in Sierra Leone is instead dozens of men and women using machetes, shovels, and their bare hands. As they touch, talk, and sweat their way across a field, the work they do is inherently connective.

“Farming unites us,” explained Bondu Lebbe, the president of the Kono Women’s Cooperative, a marketing collective whose aim is to empower its 5,000 female members. (Ngekia is a chairwoman.) Before Ebola, the cooperative would normally assemble 100 or 200 people at a time to work in members’ fields. “It’s not like in Europe,” she told me. “When we go to the farm, we come together. We talk about our families. We solve our problems. We give courage to each other.”

Over the past year, farming in much of Sierra Leone has been hindered by the disconnection Ebola demands and the distrust that disconnection breeds. In telephone interviews, farmers and agricultural officials described the same scenarios repeatedly. Many farmers are afraid to hire the additional hands they need for planting, weeding, and harvesting, thinking outsiders might bear the disease. Many workers fear farmers, like Ngekia, whom they suspect of having some link to Ebola. And the seasonal migration of laborers has been obstructed by lockdowns that force people to stay in one place and blockades that impede movement when migration is allowed.

Even when manpower is available, critical mass is hard to achieve. In most cases, the government has prohibited gatherings of more than five people. Lebbe said that her planting crews are now small, and in the field people keep their distance from one another. But that is better than nothing at all. In the areas hardest hit by Ebola, an uncounted number of farms lie fallow—because farmers died, because farm families were shattered by death, or because people simply abandoned their land, having run away to escape the threat of disease or the pain of losing loved ones to it.

Rice has gone unplanted in some places and unharvested in others. Where labor was in short supply to defend against weeds, rodents, and birds, yields have suffered. Some areas unscathed by Ebola have still struggled: Even as farmers have harvested good crops of rice and other foods, they have been challenged to sell them because markets are closed and roads are blocked.

So now the intense-transmission countries face what you might call a Catch-44, a double Catch-22:

• To prevent the spread of Ebola, we have to cripple agriculture.

• To save them from malnutrition and outright famine, we have to persuade rich countries to send food.

• But if we send food, we'll undercut local farmers (as we did in Haiti) and make those countries permanently dependent on cheap foreign food.

• Then impoverished farmers will move to the cities, live in squalor, and create conditions for the next round of Ebola.

December 31, 2014

One of the maddening but fascinating aspects of following outbreaks is that you can always expect the unexpected: some hitherto unknown bacterium or virus suddenly makes its debut (usually in a poor or repressive country with terrible online news coverage), and everything goes topsy-turvy.

The end of the year is as good a time as any to reflect on this aspect of global health, so I've looked back at what this blog was following on December 31 of the last few years:

2011: People worried about "gain of function" research into H5N1—a controversy that continues. China reported a bird flu death in Shenzhen, but it too was H5N1, with H7N9 still unknown to human immune systems. Hong Kong was banning poultry imports from some parts of Guangdong province. Bangladesh was also worried about H5N1 in poultry.

2012: Uganda was looking back on a bad year, dealing not only with cholera but with 20 Ebola deaths. The measles toll in Pakistan in December had reached 154. Sri Lanka had lost 221 people to dengue.

2013: WHO reported six new MERS cases. An 86-year-old man in Hong Kong had contracted H9N2 in Shenzhen. ECDC reported chikungunya on the Caribbean island of Saint Martin and H7N9 in China.

In December 2011, the MERS cases in Jordan were still over three months away, and the big outbreak in Saudi Arabia wouldn't start until September. In December 2012 we were over two months away from the thousands of pig carcasses floating in the Huangpu River, shortly to be followed with the first human H7N9 cases. In December 2013 we could at least glimpse the rapid spread of chikungunya in the Americas, but we had no idea of the Ebola disaster already afoot in Meliandou, Guinea (or the Canadian nurse who would soon return home from Beijing with a fatal case of H5N1).

Man proposes, disease disposes: Year after year we have proudly assessed our capacity to halt outbreaks, and year after year our healthcare systems have not quite lived up to their billing. Who knew that the Saudis, with all their money, had such pre-Semmelweiss infection control in their hospitals? Who knew that the Chinese, with all their money, would still be unable to stamp out H7N9? And who knew that the Americans and Brits would trip over themselves about imported Ebola cases—nurse Pauline Cafferkey being only the most recent case?

In some cultures, 100% success is the presumed default state. Any lapse must therefore be suppressed, ignored, or explained away. That was the Chinese response to SARS, but by H7N9 they had learned better. It's still the attitude of the Saudis, or we would know far more about MERS than we do. The US and UK embarrassed themselves by mishandling the fact that their nurses—their nurses!— had contracted Ebola and been allowed to travel.

Wiser cultures know better, grateful for their mistakes—for without recognizing those mistakes, they would go on making them and thereby killing more of their people. They see perfectionism as a form of incompetence that allows no fallback, no retreat from Stalingrad.

As a science-fiction writer, I have an innate inability to foresee the future; my profession always misses some minor but critical development like the personal computer. But if I were to venture a cautious forecast, I would offer these guesses at the events in global health in 2015:

• Continuation of endemic cholera in Haiti, and no compensation from the UN for its infliction of avoidable death and misery.

• Continuation of chikungunya's march across the Americas, with serious damage to the tourism and cruise-ship industries in the Caribbean and to the economies of the affected countries.

• Establishment of Ebola as an endemic disease in West Africa, permitting the rest of us to forget about it and get back to serious stuff like the next celebrity scandal.

• A similar apathy toward the malnutrition and outright famine triggered by Ebola across West Africa, not to mention the decades-long consequences of a generation stunted and stupefied by inadequate food.

• No outbreak of any disease that will affect Europe and North America seriously enough to make their terrified voters agree to spend money to stamp it out both at home and abroad. We will continue to rely on the mad saints of MSF and other global-health organizations to save us from ourselves.

• No pandemic, least of all with zombies in the streets. Just the routine, unnoticed sickness and deaths of many millions, mostly toddlers, from boring stuff like malaria and diarrhea.

All of this notwithstanding, I wish all of you (and especially the mad saints) a very happy, tranquil, and outbreak-free 2015.

• 15,438 mt of food delivered to 1.1 million people since April 2014*;

• 1,371 responders transported by UNHAS, with two planes and one helicopter in opertion; and

• 34,649 m3 of medical cargo transported.

Highlight— Medical Supplies Dispatched from Monrovia to Bamako

Following the first case of Ebola detected in Mali on 23 October, a United Nations Humanitarian Air Service (UNHAS) aircraft flew critical medical supplies on behalf of the World Health Organization from Monrovia to Bamako on 24 October. The supplies included personnel protection equipment kits, gloves, face shields and buckets.

UNHAS, managed by WFP, dispatched a special flight adapting a plane normally used for the transport of humanitarian workers to make space for the medical cargo. The medical items came from a 3,000 m2 humanitarian hub in Monrovia dedicated to the Ebola response, established in September by the Logistics Cluster, which groups UN agencies and non-governmental organizations, and is managed by WFP.

• The current Ebola Virus Disease outbreak in West Africa is the world’s largest Ebola outbreak recorded to date. The epidemic is severely affecting Guinea, Liberia and Sierra Leone, resulting in deaths and adversely impacting the food security of affected populations.

• If not addressed now, the consequences of the outbreak could lead to long-lasting impacts on farmers' livelihoods and rural economies. A multisectoral approach is required to contain the outbreak and stabilize affected areas.

• FAO is urgently calling for USD 30 million to support activities linked to its Regional Response Programme to the Ebola Virus Disease Outbreak over the next 12 months in Guinea, Liberia, Sierra Leone and at-risk countries. FAO is following a twin-track approach to help halt the tragic loss of life while at the same time protecting incomes, nutrition levels and food security.

BACKGROUND

The areas with high incidences of the Ebola Virus Disease (EVD) are among the most productive regions of the three affected countries (Guinea, Liberia and Sierra Leone), with both cash and food crop production impacted.

The outbreak has caused serious incomes opportunities losses, market disruptions and restricted trade flows both internally and across borders, leading to food price spikes in several markets, notably in Liberia. However, prices of some agricultural commodities have fallen significantly in producing areas, negatively affecting farmers’ income and access to food.

CHALLENGES FACING AGRICULTURE AND FOOD SECURITY

• Disruption of market linkages due to travel restrictions, leading to sharp price hikes and incomes opportunities losses.

• The likely labour shortages on farms would have severe implications for food and cash crop production in the affected areas, with the start of the crop harvesting, mainly rice and cocoa.

• Reduced crop production forecasts reported in areas with high incidences of EVD, which constitute some of the most productive regions of Sierra Leone and Liberia.

This increasingly worries me: That the collateral damage from Ebola will cripple the basic means of life in West Africa, causing vastly more loss of life than Ebola ever will, not to mention the stunting of a whole generation of children. I would hate to see the UN segue from begging for Ebola funding to begging for food relief.

October 16, 2014

Sierra Leone’s fields are without farmers. Its crops go un-reaped. In the quarantine areas, feeding is patchy – some get food, others don’t. People then leave the enforced isolation in search of a meal, so Ebola spreads. In three West African countries where many already live a hand-to-mouth existence, the act of eating is increasingly rare.

Ebola, the virus that has ravaged Sierra Leone, Liberia and Guinea at an unprecedented rate, continues its devastating spread. The number of dead doubles with each passing month; the bodies unburied. More lives are devastated with each passing day.

And in the absence of a mass-produced vaccine, its treatment – enforced isolation, mass quarantines – now threatens to bring a new crisis: starvation. Earlier this month, two children who were among the thousands orphaned by the virus, were visited by aid workers in Liberia’s capital, Monrovia. At the time, the workers did not have the resources to take the children away. When they returned days later, the children were dead. They died not from Ebola, but starvation.

Yesterday, as the World Health Organisation warned that more than 4,500 people would be dead before the end of the week, a new threat to West Africa’s stability emerged: three quarters of a million people may die from malnutrition, as an unprecedented modern famine follows the disease – if urgent action is not taken.

While Ebola’s direct consequences prompt terror, its indirect results are equally disturbing – food prices spiral, farms are abandoned, meals are scarce and those most in need, the estimated 4,000 orphans of the virus, go hungry.

Speaking on the eve of World Food Day, Denise Brown, the United Nations World Food Programme’s regional director for West Africa, said: “The world is mobilising and we need to reach the smallest villages in the most remote locations. See the Ebola outbreak mapped 1 of 7 Next

“Indications are that things will get worse before they improve. How much worse depends on us all.”

The UN agency estimates that it has provided food to a little over half a million people in the three worst-hit countries. It is aiming to feed at least another 600,000 before the end of October.

If the number of Ebola cases continues to rise exponentially over the coming months, FEWS NET anticipates that a major food crisis would occur. Under such a scenario, fears of the disease and official restrictions on movement would severely disrupt market functioning, contribute to significantly below-average household incomes, and lead to food shortages at local markets.

Large populations would face moderate to extreme food consumption gaps, equivalent to Crisis (IPC Phase 3) and Emergency (IPC Phase 4) food insecurity, by March 2015. Households with family members who have been ill or have died from Ebola, as well as poor households dependent on markets to access food, would face the most severe food security outcomes.

In addition to efforts to reduce the spread of the disease, contingency planning for an expanded emergency food assistance response is urgently needed given that the size of the food insecure population could be two to three times higher than currently planned.

As of October 8th, 8,376 cases of Ebola had been reported in Guinea, Liberia, and Sierra Leone. The size of the population that will ultimately contract Ebola remains very uncertain. However, modeling by both the U.S. Centers for Disease Control and the World Health Organization suggest that the number of cases is likely to grow substantially, even with the response to date.

Based on current information, FEWS NET has constructed a scenario using a planning figure of 200,000-250,000 cumulative Ebola cases by mid-January 2015 across the three worst affected countries.

Based on this assumption, FEWS NET would anticipate the following:

• The availability of food on local markets will be severely disrupted, due to increasing trader fears of contracting Ebola, official and unofficial restrictions on population movement, increased trader and importer operating costs, market closures, and the possibility of currency depreciation.

• Reduced incomes will limit household food access, even if it is still available at local markets. Both rural and urban households would experience significant declines in income from most sources (e.g., agricultural labor, petty trade, and the sale of forestry products, bush meat, and crops) due to the effects of a general economic slowdown and major market disruptions.

• Main season rice harvests will be average to below average. In most areas, favorable 2014 rainfall conditions contributed to normal crop growth and development. However, in rural areas worst affected by the outbreak, recent reports indicate that some fields were abandoned and that collective harvesting teams have quit operating. Instead households in these areas are generally harvesting using only family labor. This may lead to slightly below-average harvests in localized areas, particularly those where landholdings are comparatively larger. For households with members who are ill or have died from Ebola, the loss of productive household members will also contribute to below-average harvests.

• Agricultural households will increase consumption of locally produced cassava, delaying the need to source food from local markets. Cassava harvesting occurs year-round and requires less labor for harvesting than other crops.

When a major NGO starts thinking and planning in terms of 200,000-250,000 cases by mid-January, I start to worry.